And yet again, ABA: what’s wrong with it, and what can be changed

Some thoughts that keep floating around in my mind lately, particularly in response to conversations I see on social media:

I’ve said some positive things in the past about certain versions and applications of ABA. While I’m not retracting those statements, I feel I need to point out a few things.

[UPDATE, Dec 2022: At this point, I do retract any support for ABA, both as a field of study and as an industry. The more positive therapies that I have seen may have been called “ABA,” but they actually weren’t — they were multidisciplinary approaches that included a behaviorist element. See point 1 below. I do still believe there are useful lessons to be learned from the field of behaviorism, but ABA has taken those lessons and quite frankly weaponized them against people with disabilities.]

1. Apparently, I have been privileged to meet some truly unusual people in the field, and some companies that are so far from anything Lovaas envisioned that I don’t think he’d recognize them as ABA at all. Yes, they are behaviorism-based programs intended to alter a person’s behavior, and I know some people are categorically against this. But, honestly, all good parenting has to include some similar method for steering a child towards better and more adult behavior: incrementally, calmly, and consistently.

2. The examples I’ve seen of ideal ABA use are almost all with children whose primary diagnosis is not autism. I am realizing more and more how important this factor is. Kids who have a global developmental delay for some other reason (such as Down’s syndrome, cerebral palsy, or a chromosomal disorder) are often given a secondary diagnosis of autism based primarily on language delay and a bit of stimming, and I suspect they are mostly given the diagnosis in order to qualify for getting ABA covered by their insurance. And, because a lot of these kids are not really, or at least not very, autistic, the goals of an ABA program are much more in line with a developmental trajectory that makes sense for them. Which is, in short, a lot more like a neurotypical developmental trajectory, but slower and with modifications, than it is like the developmental trajectory of most autistic people.

So, yet again, what distinguishes “good ABA” from classic ABA? It’s not the lack of aversives (what most parents call “punishment”). It’s not the fact that they no longer believe in stopping kids from stimming (although that is definitely a necessary step in the right direction!).

Here are the major factors I’ve observed.

1. Good ABA consists of sessions that are no more than 1-2 hours a day, with multiple breaks, and not every day. This is a way to guarantee that even if traumatic factors remain, they are not the entirety of that child’s world. It also gives you the chance to see whether or not sessions are making your kid feel more stressed or not.

2. Good programs focus on goals that are genuinely useful. Not eye contact and writing your name, but things like:
– the ability to communicate reliably through some method (but not insisting on a single form of communication)
– safety skills like responding to the word “stop!”
– self-care skills like hand-washing, and, for older kids, independence skills like preparing food.
This alone is not enough to make a program non-abusive, but again, it’s an important place to start. Enduring something that the kid dislikes or finds uncomfortable may be a goal at times, but only when that something is hard to avoid/accommodate any other way.

3. Not pushing past a child’s tolerance level. Good programs teach and respect the use of the word “no.” They back off when they see a child becoming frustrated with a task. They don’t use physical force against a kid (yes, there are actually companies that have a “never restrain a client” rule). In short, they allow the kid some measure of control, which is probably the most critical factor in countering the abusiveness of traditional ABA. Obviously, there is still a power dynamic involved, and kids are still asked to do things they don’t like, but that’s true of almost all interactions between kids and adults. There is a big difference between getting a kid to follow a lot of the rules that other kids have to follow and demanding total, unquestioning obedience. I’ve certainly seen “ABA” sessions that involve more input from the kid than most classroom situations.

By now, anyone who endured classic ABA (or something close to it) is probably shaking their head, rolling their eyes, and/or asking if this is even remotely possible within a behavioral therapy setting. I genuinely believe that it is. Whether it should still be called ABA is a totally different issue, and a highly contentious one at that. [UPDATE. Dec 2022: No, it should not still be called ABA]

I’ve certainly witnessed sessions that met all these criteria. And, fortunately, very few that failed entirely on all these counts. Most commonly, though, I see either problematic methods with sensible goals (which is a hard one for me to know what to think about), or acceptable methodology with questionable goals.

Does meeting all these criteria make “ABA” perfect? No. Is there still room for abuse? Of course. There is also significant potential for abuse (intended or not) in any parenting situation, educational setting, and interaction with other children (in fact, I think kids are pretty much guaranteed to traumatize one another– have any of us, autistic or not, truly never met a bully, had a traitorous friend, or been mocked by our peers? I’d be very surprised.)

And there are other issues, including the stigma of being in therapy at all (although many programs are now so play-based and naturalistic that younger kids probably wouldn’t even identify them as anything other than having a slightly weird babysitter…). There is the fact that ABA practitioners don’t tend to respect the intelligence of their clients even when they do respect things like their sensory needs. But that, too, is by no means limited to ABA people– I’ve seen enough teachers use that high-pitched sing-song voice and appalling phrasing with neurotypical kids (the primary difference may, in fact, be that autistic kids are likely pick up on the fact that this is insulting far earlier than NT ones do). At least the good ones practice what they preach. They wait patiently, they take turns, they say please and thank you to their clients. How many of them mean it is another matter. But at least they understand that you have to show respectful behavior in order to expect respectful behavior, even if you’re only giving lip service. I know a few parents who could stand to learn that lesson

There’s the fact that repetition is not the best way for most autistic kids to learn, especially when it comes to intellectual skills (it may be helpful for procedural memory and building good habits, though). And, while I’ve met plenty of ABA folks who are genuinely fond of their clients, it is still very rare to find anyone in the field who truly believes that being autistic is not only OK but something to be appreciated.